Microsoft word - cms step therapy_v2_10 26 12.docx

SelectHealth Advantage
2013 Step Therapy Criteria
Step Therapy GroupAlgorithm
Step 1: ALENDRONATE SODIUM Step 2: ACTONEL, ATELVIA Previous trial on at least ONE of the following: Atacand, Atacand HCT, Step 1: ATACAND, ATACAND HCT, BENAZEPRIL HCL, BENAZEPRIL- HYDROCHLOROTHIAZIDE, BENICAR, BENICAR HCT, CAPTOPRIL, CAPTOPRIL-HYDROCHLOROTHIAZIDE, DIOVAN, DIOVAN HCT, EDARBI, EDARBYCLOR, ENALAPRIL MALEATE, ENALAPRIL- HYDROCHLOROTHIAZIDE, EPROSARTAN MESYLATE, FOSINOPRIL SODIUM, FOSINOPRIL-HYDROCHLOROTHIAZIDE, IRBESARTAN, IRBESARTAN-HYDROCHLOROTHIAZIDE, LISINOPRIL, LISINOPRIL- HYDROCHLOROTHIAZIDE, LOSARTAN POTASSIUM, LOSARTAN- HCTZ, lisinopril, lisinopril-HCTZ, HYDROCHLOROTHIAZIDE, MICARDIS, MICARDIS HCT, QUINAPRIL HCL, losartan, losartan-HCTZ, Micardis, QUINAPRIL-HYDROCHLOROTHIAZIDE, RAMIPRIL, TEVETEN, TEVETEN Micardis HCT, quinapril, quinapril- HCT Step 2: AMTURNIDE, VALTURNA HCTZ, ramipril, Teveten, Teveten HCT Previous trial on at least ONE of the Step 1: ABILIFY, ABILIFY DISCMELT, CLOZAPINE, OLANZAPINE, OLANZAPINE ODT, QUETIAPINE FUMARATE, RISPERIDONE, RISPERIDONE ODT, SYMBYAX, ZIPRASIDONE HCL Step 2: FANAPT, INVEGA, LATUDA, quetiapine, risperidone, risperidone SAPHRIS SelectHealth Advantage
2013 Step Therapy Criteria
Step Therapy GroupAlgorithm
Previous trial on at least TWO of the following: buprenorphine Step 1: BUPRENORPHINE HCL, BUTRANS, EXALGO, FENTANYL, KADIAN, LEVORPHANOL TARTRATE, METHADONE HCL, METHADOSE, MORPHINE SULFATE ER, NUCYNTA ER, OPANA ER, OXYCONTIN, OXYMORPHONE HCL methadone, morphine ER, Nucynta Step 2: AVINZA ER, Opana ER, OxycontinPrevious trial on BOTH of the Step 1: ACTONEL, ALENDRONATE SODIUM Step 2: IBANDRONATE SODIUM Actonel Previous trial on at least TWO of the following: Avinza, Step 1: AVINZA, BUPRENORPHINE HCL, EXALGO, FENTANYL, KADIAN, LEVORPHANOL TARTRATE, METHADONE HCL, METHADOSE, MORPHINE SULFATE ER, NUCYNTA ER, OPANA ER, OXYCONTIN, OXYMORPHONE HCL levorphanol, methadone, morphine Step 2: BUTRANS SelectHealth Advantage
2013 Step Therapy Criteria
Step Therapy GroupAlgorithm
Previous trial on at least ONE of the following: atorvastatin, lovastatin, Step 1: AMLODIPINE BESYLATE, ATORVASTATIN CALCIUM, LOVASTATIN, PRAVASTATIN SODIUM, SIMVASTATIN Step 2: CADUET Step 1: DICLOFENAC POTASSIUM, DICLOFENAC SODIUM, IBUPROFEN, MELOXICAM, NABUMETONE, NAPROXEN, NAPROXEN SODIUM, Previous trial on at least ONE of the Step 1: BUPROPION HCL, BUPROPION HCL SR, CITALOPRAM HBR, following: bupropion, citalopram, FLUOXETINE DR, FLUOXETINE HCL, FLUVOXAMINE MALEATE, MAPROTILINE HCL, MIRTAZAPINE, PAROXETINE HCL, SERTRALINE HCL, VENLAFAXINE HCL, VENLAFAXINE HCL ER Step 2: APLENZIN, CYMBALTA, EMSAM, LUVOX CR, PEXEVA, PRISTIQ ER, VIIBRYD SelectHealth Advantage
2013 Step Therapy Criteria
Step Therapy GroupAlgorithm
Previous trial on at least ONE of the Step 1: BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, following: hydrocortisone, CLOBETASOL EMOLLIENT, CLOBETASOL PROPIONATE, HYDROCORTISONE, HYDROCORTISONE VALERATE, TRIAMCINOLONE Previous trial on at least ONE of the Step 1: LANSOPRAZOLE, OMEPRAZOLE, OMEPRAZOLE-SODIUM BICARBONATE, PANTOPRAZOLE SODIUM, PREVACID Step 2: DEXILANT Step 1: LANTUS, LANTUS SOLOSTAR, LEVEMIR, NOVOLIN 70-30, NOVOLIN N, NOVOLIN R, NOVOLOG, NOVOLOG MIX 70-30 Step 2: SYMLINPEN 120, SYMLINPEN 60 SelectHealth Advantage
2013 Step Therapy Criteria
Step Therapy GroupAlgorithm
Step 1: SPIRONOLACTONE, SPIRONOLACTONE-HCTZ Step 2: EPLERENONE spironolactone-HCTZPrevious trial on at least TWO of the following: Avinza, Step 1: AVINZA, BUPRENORPHINE HCL, BUTRANS, FENTANYL, KADIAN, LEVORPHANOL TARTRATE, METHADONE HCL, METHADOSE, MORPHINE SULFATE ER, NUCYNTA ER, OPANA ER, OXYCONTIN, OXYMORPHONE HCL levorphanol, methadone, morphine Step 2: EXALGO ER, Nucynta ER, Opana ER, Oxycontin Previous trial on generic gabapentin Step 1: GABAPENTIN Step 2: GRALISE, HORIZANT SelectHealth Advantage
2013 Step Therapy Criteria
Step Therapy GroupAlgorithm
Previous trial on at least ONE of the following: Actoplus Met/XR, Step 1: ACTOPLUS MET, ACTOPLUS MET XR, ACTOS, DUETACT, GLIMEPIRIDE, GLIPIZIDE, GLIPIZIDE ER, GLIPIZIDE-METFORMIN, GLUMETZA, GLYBURIDE, GLYBURIDE MICRONIZED, GLYBURIDE- METFORMIN HCL, JANUMET, JANUMET XR, JUVISYNC, KOMBIGLYZE XR, glyburide-metformin, Janumet/XR, METFORMIN HCL, METFORMIN HCL ER, PRANDIMET, TOLAZAMIDE, TOLBUTAMIDE Step 2: BYDUREON, BYETTA, VICTOZA 3-PAK metformin/ER, Prandimet, tolazamide, tolbutamidePrevious trial on at least ONE of the following: lovastatin, pravastatin, simvastatin, Vytorin, atorvastatin Step 1: ATORVASTATIN CALCIUM, LOVASTATIN, PRAVASTATIN SODIUM, OR previous trial on at least ONE SIMVASTATIN, VYTORIN, VYTORIN Step 2: JUVISYNC of the following: Metformin, Januvia Previous trial on at least TWO of the following: Avinza, Step 1: AVINZA, BUPRENORPHINE HCL, BUTRANS, EXALGO, FENTANYL, LEVORPHANOL TARTRATE, METHADONE HCL, METHADOSE, MORPHINE SULFATE ER, NUCYNTA ER, OPANA ER, OXYCONTIN, OXYMORPHONE HCL levorphanol, methadone, morphine Step 2: KADIAN SelectHealth Advantage
2013 Step Therapy Criteria
Step Therapy GroupAlgorithm
Step 1: ATORVASTATIN CALCIUM, CRESTOR, CRESTOR, FLUVASTATIN SODIUM, LESCOL, LESCOL XL, LOVASTATIN, PRAVASTATIN SODIUM, Crestor, atorvastatinPrevious trial on at least ONE of the Step 1: ZALEPLON, ZOLPIDEM TARTRATE, ZOLPIDEM TARTRATE ER Step 2: Previous trial on at least TWO of the following: methocarbamol, Step 1: BACLOFEN, CHLORZOXAZONE, CYCLOBENZAPRINE HCL, DANTROLENE SODIUM, METHOCARBAMOL, ORPHENADRINE CITRATE, MUSCLE RELAXANT cyclobenzaprine, dantrolene, ORPHENADRINE COMPOUND, SKELAXIN, TIZANIDINE HCL Step 2: SelectHealth Advantage
2013 Step Therapy Criteria
Step Therapy GroupAlgorithm
Previous trial on at least TWO of the following: Avinza, Step 1: AVINZA, BUPRENORPHINE HCL, BUTRANS, EXALGO, FENTANYL, KADIAN, LEVORPHANOL TARTRATE, METHADONE HCL, METHADOSE, Exalgo, fentanyl patches, Kadian, MORPHINE SULFATE ER, OPANA ER, OXYCONTIN, OXYMORPHONE HCL levorphanol, methadone, morphine Step 2: NUCYNTA ER ER, Opana ER, Oxycontin Previous trial on at least TWO of the following: Avinza, Step 1: AVINZA, BUPRENORPHINE HCL, BUTRANS, EXALGO, FENTANYL, KADIAN, LEVORPHANOL TARTRATE, METHADONE HCL, METHADOSE, Exalgo, fentanyl patches, Kadian, MORPHINE SULFATE ER, NUCYNTA ER, OXYCONTIN Step 2: OPANA ER, levorphanol, methadone, morphine OXYMORPHONE HCL ER, Nucynta ER, Oxycontin SelectHealth Advantage
2013 Step Therapy Criteria
Step Therapy GroupAlgorithm
Previous trial on at least TWO of the following: Avinza, Step 1: AVINZA, BUPRENORPHINE HCL, BUTRANS, EXALGO, FENTANYL, KADIAN, LEVORPHANOL TARTRATE, METHADONE HCL, METHADOSE, Exalgo, fentanyl patches, Kadian, MORPHINE SULFATE ER, NUCYNTA ER, OPANA ER, OXYMORPHONE HCL levorphanol, methadone, morphine Step 2: OXYCONTIN ER, Nucynta ER, Opana ERPrevious trial on at least TWO of Step 1: DEXILANT, LANSOPRAZOLE, OMEPRAZOLE, PANTOPRAZOLE SODIUM, PREVACID Step 2: NEXIUM, OMEPRAZOLE-SODIUM Dexilant Previous trial on at least ONE of the Step 1: AMLODIPINE BESYLATE, ATENOLOL, DILTIAZEM 24HR ER, following: amlodipine, diltiazem, DILTIAZEM ER, DILTIAZEM HCL, ISOSORBIDE DINITRATE, ISOSORBIDE MONONITRATE, ISOSORBIDE MONONITRATE ER, METOPROLOL SUCCINATE, METOPROLOL TARTRATE, PROPRANOLOL HCL, VERAPAMIL ER, VERAPAMIL ER PM, VERAPAMIL HCL Step 2: RANEXA SelectHealth Advantage
2013 Step Therapy Criteria
Step Therapy GroupAlgorithm
Previous trial on at least TWO of the following: hydrocodone/APAP, Step 1: ACETAMINOPHEN-CODEINE, BUTALB-CAFF-ACETAMINOPH-butalbital/APAP/caf/cod, CODEIN, CODEINE SULFATE, HYDROCODONE BIT-IBUPROFEN, HYDROCODONE-ACETAMINOPHEN, HYDROMORPHONE HCL, MORPHINE SULFATE, OXYCODONE CONCENTRATE, OXYCODONE HCL, OXYCODONE hydrocodone/IBU, hydromorphone, HCL-ACETAMINOPHEN, OXYCODONE HCL-ASPIRIN, OXYCODONE HCL-morphine IR, oxycodone, IBUPROFEN, OXYCODONE-ACETAMINOPHEN Step 2: NUCYNTA, oxycodone/ASA, oxycodone/IBUPrevious trial on at least ONE of the following: zolpidem, zaleplon AND Step 1: AMITRIPTYLINE HCL, AMOXAPINE, CLOMIPRAMINE HCL, previous trial on at least ONE of the DESIPRAMINE HCL, DOXEPIN HCL, IMIPRAMINE HCL, IMIPRAMINE PAMOATE, NORTRIPTYLINE HCL, PROTRIPTYLINE HCL, TRIMIPRAMINE MALEATE, ZALEPLON, ZOLPIDEM TARTRATE, ZOLPIDEM TARTRATE ER desipramine, doxepin, imipramine, Step 2: SILENOR nortriptyline, protriptyline, trimipramine Previous trial on at least ONE of the following: Asmanex, Advair, Step 1: ADVAIR DISKUS, ADVAIR HFA, ASMANEX, FLOVENT DISKUS, albuterol, Flovent, Pulmicort, Qvar, FLOVENT HFA, FLUNISOLIDE, FLUTICASONE PROPIONATE, NASONEX, Symbicort OR previous trial on at PROAIR HFA, PROVENTIL HFA, PULMICORT FLEXHALER, QVAR, RHINOCORT AQUA, SYMBICORT Step 2: SINGULAIR flunisolide, fluticasone, Nasonex, Rhinocort AQ SelectHealth Advantage
2013 Step Therapy Criteria
Step Therapy GroupAlgorithm
Steps
Step 1: ZOLPIDEM TARTRATE, ZOLPIDEM TARTRATE ER Step 2: EDLUAR,
Previous trial on at least ONE of the Step 1: ATORVASTATIN CALCIUM, LOVASTATIN, PRAVASTATIN SODIUM, following: lovastatin, pravastatin, SIMVASTATIN Step 2: ADVICOR, CRESTOR, SIMCOR, VYTORIN simvastatin, atorvastatinPrevious trial on at least ONE of the following: benazepril, benazepril-HCTZ, captopril, captopril-HCTZ, Step 1: ATACAND, ATACAND HCT, BENAZEPRIL HCL, BENAZEPRIL-enalapril, enalapril-HCTZ, HYDROCHLOROTHIAZIDE, BENICAR, BENICAR HCT, CAPTOPRIL, CAPTOPRIL-HYDROCHLOROTHIAZIDE, DIOVAN, DIOVAN HCT, EDARBI, ENALAPRIL MALEATE, ENALAPRIL-HYDROCHLOROTHIAZIDE, quinapril, quinapril-HCTZ, ramipril EPROSARTAN MESYLATE, FOSINOPRIL SODIUM, FOSINOPRIL- AND previous trial on at least ONE HYDROCHLOROTHIAZIDE, IRBESARTAN, IRBESARTAN-of the following: Atacand, Atacand HYDROCHLOROTHIAZIDE, LISINOPRIL, LISINOPRIL-HCT, Benicar, Benicar HCT, HYDROCHLOROTHIAZIDE, LOSARTAN POTASSIUM, LOSARTAN- HYDROCHLOROTHIAZIDE, MICARDIS, MICARDIS HCT, QUINAPRIL HCL, QUINAPRIL-HYDROCHLOROTHIAZIDE, RAMIPRIL, TEVETEN, TEVETEN HCT Step 2: TEKAMLO, TEKTURNA, TEKTURNA HCT Micardis, Micardis HCT, Teveten, Teveten HCT SelectHealth Advantage
2013 Step Therapy Criteria
Step Therapy GroupAlgorithm
Previous trial on at least ONE of the following: omeprazole, Step 1: CELEBREX, DEXILANT, DICLOFENAC POTASSIUM, DICLOFENAC SODIUM, IBUPROFEN, LANSOPRAZOLE, MELOXICAM, NABUMETONE, NAPROXEN, NAPROXEN SODIUM, NEXIUM, OMEPRAZOLE, OMEPRAZOLE- previous trial on at least ONE of the SODIUM BICARBONATE, OXAPROZIN, PANTOPRAZOLE SODIUM, meloxicam, ibuprofen, naproxen, nabumetone, diclofenac, Celebrex SelectHealth Advantage
2013 Step Therapy Criteria
SelectHealth Advantage
2013 Step Therapy Criteria
SelectHealth Advantage
2013 Step Therapy Criteria
SelectHealth Advantage
2013 Step Therapy Criteria
SelectHealth Advantage
2013 Step Therapy Criteria
TEVETEN . 1,11TEVETEN HCT . 1,11TIZANIDINE HCL . 7TOLAZAMIDE . 6TOLBUTAMIDE . 6TRAZODONE HCL . 8TRIAMCINOLONE ACETONIDE. 4TRIMIPRAMINE MALEATE . 10ULORIC . 12VALTURNA . 1VENLAFAXINE HCL . 3VENLAFAXINE HCL ER . 3VERAPAMIL ER . 9VERAPAMIL ER PM . 9VERAPAMIL HCL . 9VICTOZA 3-PAK . 6VIIBRYD . 3VIMOVO . 12VYTORIN . 6,11ZALEPLON . 7,10ZEGERID . 9ZIPRASIDONE HCL . 1ZOLPIDEM TARTRATE . 7,10,11ZOLPIDEM TARTRATE ER . 7,10,11ZOLPIMIST . 11

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